Provider Demographics
NPI:1033685516
Name:SON, SOO GYUNG (LMT, CLT)
Entity Type:Individual
Prefix:
First Name:SOO
Middle Name:GYUNG
Last Name:SON
Suffix:
Gender:F
Credentials:LMT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9860 SW HALL BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8896
Mailing Address - Country:US
Mailing Address - Phone:971-238-8756
Mailing Address - Fax:888-860-7014
Practice Address - Street 1:9860 SW HALL BLVD STE A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-8896
Practice Address - Country:US
Practice Address - Phone:971-238-8756
Practice Address - Fax:888-860-7014
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-22
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21407225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist